Lung cancer

TNM definitions

Primary tumor (T) (Fig. 14-18)

TX: Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy

T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: A tumor that is 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, and without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)*

T2: A tumor with any of the following features of size or extent:

• 
  more than 3 cm in greatest dimension
  
• 
  Involves the main bronchus, 2 cm or more distal to the carina;
  
• 
  invades the visceral pleura;
  
• 
  associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung
  

T3: A tumor of any size that directly invades any of the following:

• 
  chest wall (including superior sulcus tumors);
  
• 
  diaphragm;
  
• 
  mediastinal pleura;
  
• 
  parietal pericardium;
  
• 
  or tumor in the main bronchus less than 2 cm distal to the carina but without involvement of the carina;
  
• 
  or associated atelectasis or obstructive pneumonitis of the entire lung
  

T4: A tumor of any size that invades any of the following:

• 
  mediastinum;
  
• 
  heart;
  
• 
  great vessels;
  
• 
  trachea;
  
• 
  esophagus;
  
• 
  vertebral body;
  
• 
  carina;
  
• 
  or separate tumor nodules in the same lobe;
  
• 
  or tumor with a malignant pleural effusion **
  

*Note: The uncommon superficial tumor of any size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus, is also classified as T1.

**Note: Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients in whom multiple cytopathologic examinations of pleural fluid are negative for tumor. In these cases, fluid is non-bloody and is not an exudate. When these elements and clinical judgement dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient should be staged as T1, T2, or T3.

Regional lymph nodes (N) (Fig. 19-21)

NX: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastasis (need to examine more than 6 lymph nodes)
N1: Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes including involvement by direct extension of the primary tumor

N2: Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)

N3: Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
Distant metastasis (M) (Fig. 22)

MX: Distant metastasis cannot be assessed

M0: No distant metastasis
M1: Distant metastasis present

*Note: M1 includes separate tumor nodule(s) in a different lobe (ipsilateral or contralateral).

ABBREVIATIONS FOR M1

BRA = brain	EYE = eye	HEP = hepatic
LYM = lymph nodes	MAR = bone marrow	OSS = osseous
OTH = other	OVR = ovary	PER = peritoneal
PLE = pleura	PUL = pulmonary	SKI = skin

Fig. 14. Possible variants of T1 and T2 tumour.



Fig. 15. Possible variants of T3 and T4 tumour.

Fig. 16. Possible variants of T4 tumour.


Fig. 17. Possible variants of T4 tumour.


Fig. 18. Possible variants of T4 tumour.


Fig. 19. Possible lymph nodes affection in case of LC: 1 – segmental lymph nodes (LN), 2 – lobal LN, 3 – interlobal LN, 4 – hilar LN, 5 – tracheobronchial LN, 6 – paratracheal L:N, 7 – LN of aortal window and reccurent laryngeal nerve, 8 – LN of azygous vein, 9 – paraoesophageal LN, 10 – bifurcational LN, 11 – oesophagus, 12 – aorta, 13 – vena cava superior, 14 – azygous vein, 15 – supraclavicular LN, 16 – LN of lung ligament, 17 – lung ligament, 18 – left vagus nerve, 19 – left reccurent laryngeal nerve.



Fig. 20. Possible variants of N1 Fig. 21. Possible variants of

N2. N3 and M1.

a b c

Fig. 22. a) computed tomography scan of enhancing cerebral metastasis with marked oedema and mass effect; b) massive left adrenal (open arrow) and hepatic metastases (arrows); c) vertebral body metastasis.